All practice questions

A 71-year-old man presents to the clinic to establish care. He recently moved to the area to live closer to his family and has not seen a physician in six years. His medical history includes osteoarthritis of the knees and mild essential hypertension, both well-controlled with over-the-counter ibuprofen and lisinopril. He smoked 1.5 packs of cigarettes daily from age 20 to 50 but quit 21 years ago. He drinks one glass of wine on weekends. His previous medical records indicate that his last colonoscopy was performed at age 59 and revealed no polyps. A hepatitis C antibody test performed six years ago was negative. His most recent lipid panel and hemoglobin A1c, obtained during a community health fair last month, were within normal limits. His father died of a stroke at age 80, and his older brother was treated for localized prostate cancer at age 68. The patient is asymptomatic and his physical examination is unremarkable. Which of the following is the most appropriate combination of screening tests to recommend for this patient?

A 71-year-old man arrives at the urgent care center accompanied by his daughter. She reports that over the past 12 hours, her father has become increasingly confused, restless, and has been unable to pass urine. His medical history is notable for Parkinson disease, benign prostatic hyperplasia, and hypertension. His chronic pharmacological regimen includes carbidopa-levodopa, tamsulosin, and amlodipine, all of which have been administered at stable dosages for over two years. His daughter mentions that he developed rhinorrhea and a cough three days prior, for which he started taking a non-prescription, multi-symptom cold and sleep preparation. Vital signs show a temperature of 37.6°C (99.7°F), blood pressure of 142/88 mm Hg, heart rate of 112/min, and respiratory rate of 16/min. Physical examination is notable for dry oral mucosa, flushed skin, bilaterally dilated and nonreactive pupils, and a palpably distended lower abdomen. Bowel sounds are diminished. Laboratory analysis reveals a leukocyte count of $11,000/\text{mm}^3$. Which of the following historical elements is most critical in establishing the etiology of this patient's acute presentation?

A multidisciplinary research team at a regional veterans hospital is investigating a novel care-transition protocol for patients discharged with congestive heart failure. The primary outcome is the change in the Kansas City Cardiomyopathy Questionnaire (KCCQ) clinical summary score at 90 days. During the planning phase, a biostatistician determines that the current study protocol only has a $60\%$ probability of detecting a true difference between the intervention and usual care groups. The team needs to modify the study design to reach at least an $80\%$ probability of detecting this difference.

Which of the following modifications would independently help achieve this goal? (Select all that apply)

During a routine follow-up visit, an internal medicine physician evaluates a patient who was recently diagnosed with heart failure with reduced ejection fraction (LVEF 35%). The patient's prescribed medical regimen includes carvedilol, empagliflozin, and lisinopril. While reviewing the medication list, the patient states, "I stopped taking the lisinopril two weeks ago. A neighbor told me that those blood pressure pills destroy your kidneys. Since I feel completely fine right now, I do not want to risk kidney damage." Which of the following is the most appropriate initial response by the physician?

An intensive care unit team is evaluating a $54$-year-old man for abnormal laboratory findings. The patient was admitted to the hospital $7$ days ago for severe community-acquired pneumonia that rapidly progressed to acute respiratory distress syndrome. He required mechanical ventilation and high-dose vasopressor support for several days. Over the past $48$ hours, his clinical status has significantly improved, and vasopressors have been successfully discontinued. Routine laboratory studies obtained this morning show the following results:

Which of the following is the most likely underlying mechanism for this patient's laboratory findings?

A 55-year-old man presents to the clinic for a routine health maintenance examination. He has not seen a physician in seven years. He feels well and has no acute complaints. His only past medical history is a surgical meniscus repair in his twenties. He takes no daily medications. He is a current smoker with a 35-pack-year smoking history, and he drinks 1 to 2 beers on weekends. His body mass index is 23 kg/m². His last health care visit was at age 48, during which he underwent a screening colonoscopy that was normal. At that time, a comprehensive metabolic panel, fasting lipid panel, and HIV screening were also unremarkable. He received a Tdap booster and an influenza vaccine at a local pharmacy last month, but he has not received any other adult immunizations. Which of the following preventive interventions are indicated for this patient at today's visit? (Select all that apply)

Investigators are evaluating the risk of developing new-onset atrial fibrillation after aortic valve interventions. They query a national cardiovascular registry to identify 2,500 patients without prior arrhythmias who underwent either transcatheter aortic valve replacement or surgical aortic valve replacement between January 2017 and December 2022. The research team then examines the patients' subsequent medical records from the date of the valve intervention up to December 2025, calculating and comparing the incidence of atrial fibrillation between the two intervention groups. Which of the following best describes the epidemiological design of this investigation?

A 42-year-old woman comes to the physician due to a 3-week history of generalized weakness, fatigue, and episodic loose stools. She reports having 3 to 4 watery bowel movements daily but denies fever, abdominal pain, or blood in her stool. She has no significant past medical history and takes no medications. Her blood pressure is 110/70 mm Hg, and pulse is 88/min. Physical examination is unremarkable, with normal skin turgor and moist mucous membranes.

Laboratory studies show the following:

Which of the following is the most likely underlying mechanism for this patient's laboratory findings?

An international surgical task force is designing a randomized controlled trial to evaluate a novel topical hemostatic agent for reducing intraoperative blood loss during major hepatic resections. The primary outcome is the total volume of blood lost (a continuous variable measured in milliliters). Initial power calculations dictate a required sample size of $450$ patients to detect a clinically significant difference of $100$ mL between the novel agent and standard care, assuming a significance level ($\alpha$) of $0.05$ and $80\%$ statistical power ($1 - \beta$). However, due to the rarity of the specific surgical indications, the task force anticipates a maximum enrollment of only $250$ patients over the study period. Which of the following modifications to the study design is most appropriate to maximize the statistical power of the trial given the constrained sample size?

A 32-year-old woman is evaluated in the emergency department for a 2-week history of progressive dyspnea on exertion, orthopnea, and bilateral lower extremity edema. She recently immigrated to the United States and has not yet established care with a primary care physician. She states that she has "always been healthy" and has not seen a doctor in several years. Vital signs are significant for a heart rate of 115/min and blood pressure of 105/65 mm Hg. Physical examination reveals elevated jugular venous pressure, bibasilar lung crackles, and an S3 gallop. Echocardiography demonstrates a dilated left ventricle with a left ventricular ejection fraction of 25% and global hypokinesis.

In determining the underlying etiology of her newly diagnosed non-ischemic dilated cardiomyopathy, which of the following elements of her medical and social history are critical to elicit? (Select all that apply)

A city health commission is analyzing a recent localized cluster of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in a specific neighborhood. The researchers identify 80 residents who tested positive for the virus and developed symptoms during a two-week period. They also recruit 160 residents from the same neighborhood who tested negative and remained asymptomatic during the same timeframe. Both groups are administered a detailed questionnaire regarding their attendance at various local indoor venues (e.g., gyms, restaurants, grocery stores) over the preceding month. The researchers aim to determine which specific venues are associated with the highest risk of viral transmission by comparing the frequency of attendance between the two groups. Which of the following best describes the study design utilized in this investigation?

A 44-year-old man is brought to the outpatient clinic by his spouse due to a three-day history of worsening unsteadiness, confusion, and a noticeable hand tremor. He has a history of bipolar disorder that has been well controlled on a stable dose of lithium for the past five years. His other medical conditions include mild essential hypertension and recently diagnosed right knee osteoarthritis. A review of his electronic health record reveals no new prescriptions or dosage changes from his care team over the last six months. His vital signs are within normal limits. On physical examination, he exhibits a coarse bilateral tremor and a broad-based, unsteady gait. Which of the following specific historical inquiries is most critical to establishing the etiology of his current presentation?

A team of cardiologists is designing a randomized controlled trial to evaluate the efficacy of a novel supervised cardiac rehabilitation protocol compared to standard care. The primary outcome is the continuous change in the 6-minute walk test distance over 12 weeks. Initial sample size calculations indicate that 400 patients are required to achieve 80% power to detect a true difference of 25 meters between the groups, using a standard $\alpha$ level of 0.05. However, due to unexpected budget reductions, the maximum number of patients that can be enrolled is capped at 250. The investigators still wish to maintain 80% statistical power without altering the minimum clinically important difference (25 meters) or the significance level ($\alpha = 0.05$). Which of the following study modifications would best help achieve this goal?

An academic surgical collaborative is finalizing the protocol for a randomized controlled trial comparing a new robot-assisted technique to traditional laparoscopic cholecystectomy for patients with symptomatic cholelithiasis. The primary outcome is the rate of major biliary complications within 30 days post-operation. The trial is initially powered at $80\%$ to detect a $3\%$ absolute reduction in complications, using a preset significance level ($\alpha$) of $0.05$. During the scientific review board meeting, a reviewer raises concerns about the potential for adopting an inferior, more expensive technique based on a false-positive finding. To address this concern, the principal investigator amends the protocol to use a stricter significance level of $0.01$ instead of $0.05$. Assuming the planned sample size and the anticipated absolute risk reduction remain unchanged, which of the following is the most likely statistical consequence of this protocol amendment?

A hospital infection control committee is investigating an unusual cluster of central line-associated bloodstream infections (CLABSIs) in the medical intensive care unit. Over the last quarter, 15 patients developed the infection. To identify potential risk factors, the committee plans to compare the clinical records of these 15 patients against 60 randomly selected patients who had central lines in the same unit during the identical time frame but did not develop the infection. The investigators aim to evaluate various prior exposures, such as the type of sterile dressing used, the duration of catheterization, and the specific personnel performing the insertion. Based on this proposed methodology, which of the following statements are accurate? (Select all that apply)

A 55-year-old woman presents to the clinic to review the results of a recent breast biopsy. The physician is preparing to deliver the diagnosis of invasive ductal carcinoma. According to the SPIKES protocol for delivering bad news, arrange the following physician actions and statements in the correct chronological order.

An inpatient diagnostic laboratory is correlating cerebrospinal fluid (CSF) analysis patterns from multiple lumbar punctures with their corresponding clinical etiologies. Assume a concurrent normal serum glucose of $90\text{ mg/dL}$ for all patients. Match each distinct CSF laboratory profile to the most likely associated diagnosis.

An occupational medicine research group is investigating the health outcomes of workers who were exposed to a specific, newly synthesized industrial solvent during a 6-month manufacturing period 15 years ago. Only 350 workers were ever exposed to this chemical before the manufacturing process was permanently altered. The researchers aim to determine if these exposed workers have an increased incidence of various hepatic and neurologic disorders compared to unexposed workers at the same facility. Comprehensive medical records and employment logs from the past two decades are available for all workers. Which of the following epidemiological study designs is most appropriate for this investigation?

A 64-year-old man comes to the office for a routine follow-up evaluation. Three weeks ago, he was hospitalized for a non-ST-segment elevation myocardial infarction and was discharged on aspirin, ticagrelor, atorvastatin, and metoprolol. Today, his blood pressure is 128/78 mm Hg and heart rate is 68/min. During the interview, the patient states, "I stopped taking the atorvastatin and ticagrelor a few days ago. I read online that statins can completely destroy your liver. Also, my neighbor told me that a high-dose natural garlic extract thins the blood just as well as prescription drugs, without all the toxic chemicals, so I started taking that instead."

Which of the following is the most appropriate initial response by the physician?

A 45-year-old woman comes to the outpatient continuity clinic with a 4-month history of episodic shortness of breath, low-grade fever, chills, and a dry cough. She reports that her symptoms typically begin on Saturday evenings, persist through Sunday, and gradually resolve by Tuesday. Her past medical history is significant for gastroesophageal reflux disease (GERD) and allergic rhinitis. Her current medications are omeprazole and as-needed cetirizine. She is a lifelong non-smoker and works Monday through Friday as an accountant in a corporate office. Vital signs are temperature 37.8°C (100.0°F), pulse 92/min, respirations 18/min, and blood pressure 128/82 mmHg. Pulse oximetry shows 94% on room air. Lung auscultation reveals bilateral fine crackles without wheezing. Laboratory studies show a mild peripheral eosinophilia of 6% (normal: 1-5%). A recent trial of an albuterol inhaler prescribed at an urgent care clinic provided no symptom relief. Which of the following areas of medical history is most critical to investigate next to establish the correct diagnosis?